The authors reviewed 2,574 visits and identified 36 patients diagnosed with cyclic vomiting over 128 visits. The prevalence of cyclic vomiting visits increased from 41 per 113,262 ED visits to 87 per 125,095 ED visits after marijuana liberalization, corresponding to a prevalence ratio of 1.92 (95% confidence interval [CI] = 1.33 to 2.79). Patients with cyclic vomiting in the postliberalization period were more likely to have marijuana use documented than patients in the preliberalization period (odds ratio = 3.59, 95% CI = 1.44 to 9.00).

For background on the slow, Case Report driven appreciation that a chronic cyclical vomiting syndrome can be caused by cannabis use, see blog posts here, here, here.

The major takeaway message is that when physicians or patients are simply aware that there is this syndrome, diagnosis can be more rapid and a lot less expensive. Patients can, if they are able to stop smoking pot, find relief more quickly.

As far as the present report showing increasing rates in CO, well, this is interesting. Consistent with a specific causal relationship of cannabis use to this hyperemesis syndrome. But hard to disentangle growing awareness of the syndrome from growing incidence of it. We'll just have to follow these relationships as more states legalize medical and recreational marijuana.

Surgeon General's Report On Alcohol, Drugs and Health can be found at addiction.surgeongeneral.gov. You may be particularly interested in the Executive Summary [PDF] or the chapter on the Neurobiology of Addiction [PDF].

In 2015, substance use disorders affected 20.8 million Americans—almost 8 percent of the adolescent and adult population. That number is similar to the number of people who suffer from diabetes, and more than 1.5 times the annual prevalence of all cancers combined (14 million). Of the 20.8 million people with a substance use disorder in 2015, 15.7 million were in need of treatment for an alcohol problem in 2015 and nearly 7.7 million needed treatment for an illicit drug problem.

Substance use disorder treatment in the United States remains largely segregated from the rest of health care and serves only a fraction of those in need of treatment. Only about 10 percent of people with a substance use disorder receive any type of specialty treatment. Further, over 40 percent of people with a substance use disorder also have a mental health condition, yet fewer than half (48.0 percent) receive treatment for either disorder.

Treatment is effective. As with other chronic, relapsing medical conditions, treatment can manage the symptoms of substance use disorders and prevent relapse. Rates of relapse following treatment for substance use disorders are comparable to those of other chronic illnesses such as diabetes, asthma, and hypertension. More than 25 million individuals with a previous substance use disorder are in remission and living healthy, productive lives.

For instance, people who first use alcohol before age 15 are four times more likely to become addicted to alcohol at some time in their lives than are those who have their first drink at age 20 or older. Nearly 70 percent of those who try an illicit drug before the age of 13 develop a substance use disorder in the next 7 years, compared with 27 percent of those who first try an illicit drug after the age of 17. Although substance misuse problems can develop later in life, preventing or even just delaying young people from trying substances is important for reducing the likelihood of more serious problems later on.

Many more people now die from alcohol and drug overdoses each year than are killed in automobile accidents. The opioid crisis is fueling this trend with nearly 30,000 people dying due to an overdose on heroin or prescription opioids in 2014. An additional roughly 20,000 people died as a result of an unintentional overdose of alcohol, cocaine, or non-opioid prescription drugs.

In terms of health and biomedical science, the Reagan Administration left a shameful legacy of refusing to respond to (or acknowledge, really) the HIV/AIDS crisis that blew up during their tenure in office.

If you are a reader of my posts on drug abuse science you will have noticed that it rarely takes long for a commenter or three to opine some version of "The (US) War on Drugs is a complete and utter failure". Similarly, while Big Eddie mostly comments on the liberty aspects (rather than the effectiveness) of the WoD himself, a commenter to his posts will usually weigh in, commenting to a similar effect.

Now I'm open to all the arguments about personal liberty trade offs, economic costs, sentencing disparities, violations of other sovereign nations and the like. Nevertheless, I'm most interested in the fundamental question of whether the War on Drugs worked. That is, to reduce drug use in the US. For those who believe it has not worked, I have a few figures I would like explained to me.

I'm following up a story I started in a prior post by putting up the long term trends for cocaine use in the US. These data are from the 2006 Volume II monograph which focuses on the 18 yr old and older populations. As you will recall my hypothesis was / is that the Len Bias fatality had a dramatic effect on cocaine use. I still think this is the case and that this explains much of the timing of a reduction in cocaine prevalence observed consistently from the 18 yr old to 45+ age groups. However Len Bias's death was not an exclusive effect and must be considered in the context of changes in other drug use patterns. That context is something I want to delve into just a little bit.

As always, I depend on the data from the Monitoring the Future survey (www.monitoringthefuture.org) and I am pulling the figures from the 2006 Volume I monograph which focuses on the 8th, 10th and 12th grade populations in contrast to the older age cohorts outlined in the first graph.

Cocaine

First up are the annual prevalence rates for powder cocaine, which I provide for reference to the previous graph for the older age ranges. I apologize for the blurry figures but my imaging skills are not up to any better- luckily, these reports are freely available on the MtF website. (I also encourage you to get the reports yourself because there are slight changes in the questions asked in some cases- if you see a discontinuity in the longitudinal data this is probably why.) The longest term trends are available for 12th graders, additional grades were added into the survey in the early 1990's. Prevalence of cocaine was reasonably steady in the 1979-1986 interval and it is stunningly apparent that cocaine became less popular with 12th graders after 1986 . It is also clear that it took about 5 additional years for prevalence to drop to the most recent nadir. So it wasn't all about Len Bias (he died of cocaine-related cardiac complications on June 19, 1986).
So, if it isn't all about Len Bias, perhaps we should see similar effects on population prevalence of other illicit drugs?

Marijuana and Amphetamine

It seems reasonable to turn our analysis to two perennial high-prevalence drugs for high school populations; marijuana (duh!) and the amphetamines. (In MtF parlance, the amphetamine class is for tablet or other prescription preparations after 1982.) In this case, the prevalences were at peak in the late 1970s and started to decline in the very early 1980s. Interestingly, there is no evidence of a change in the established trends from 1986-1987 as is observed for powder cocaine; I think this supports the Len Bias hypothesis. Nevertheless we can also see this as additional evidence for something else driving drug use downward.

This brings us to what are illicit drugs for most of these populations but, of course, licit drugs for individuals who have reached the legal age; 21 (alcohol) or 18 (cigarettes; this may be a substantial fraction of 12th graders). In theory, we might use these data to try to dissociate the anti-drug messaging from the drug interdiction / legal penalties side of the equation. Not perfect, but at least a hint.

Alcohol

The trends for annual prevalence of alcohol were very stable from 1978-1988 whereupon a decline was observed (questions were altered in 1993, making further comparison tricky). The trends for 5-drinks-in-a-row (currently the definition of a "binge") in the past two week interval were very stable from 1978-1983 and thereafter exhibited a slow decline until the early 1990s. Very reminiscent of the above mentioned drugs.

Cigarettes

In this case, please note that we've shifted to 30-day prevalence rates (any, daily); obviously this is frustrating for direct comparison but this is what they provide in the monographs. Unfortunately the more recent monographs (it is currently on a reliable annual update schedule with available pdfs, the older ones are not available) seem to only start with the 1986 data in the Tables so one is left with their figures for the earlier part of the trends. With that caveat, we can see that cigarette prevalence in the high school population was reasonably stable during the interval in which the prevalence rates for the illicit-for-all drugs mentioned above were in decline.

So Did the War on Drugs Work or Not?

I do think the jury is still out on this one and the problem of shifting definitions about goals and successes is quite difficult. I feel confident the comments will stray afield a bit and explore some of these issues. However, as I intimated at the outset,
for those of you who insist vociferously that the War on Drugs (considered inclusively with the Just Say No, D.A.R.E, main-stream media reporting, and all that stuff that is frequently rolled into a whole by the legalization crowd) is an abject failure...

for those of you who insist vociferously that you cannot tell teenagers anything about the dangers of recreational drugs and expect them to listen to you...

A public science service modeled on 23andme where you send in your pot sample for both genetic analysis ("You have new strain-relatives, want to connect and share experiences?") and content of various cannabinoids and what not. Add in some health survey stuff and away we go.

(1) A person commits the offense of use of marijuana while driving if the person uses any marijuana while driving a motor vehicle upon a highway.

(2) The offense described in this section, use of marijuana while driving, is a Class B traffic violation.

a related item that I like because it calls for research:

(4) On or before January 1, 2017, the commission shall:

(a)Examine available research, and may conduct or commission new research, to investigate the influence of marijuana on the ability of a person to drive a vehicle and on the concentration of delta-9 tetrahydrocannabinol in a person's blood, in each case taking into account all relevant factors; and
(b) Present the results of the research to the Legislative Assembly and make recommendations to the Legislative Assembly regarding whether any amendments to the Oregon Vehicle Code are appropriate.

(13) "Marijuana extract" means a product obtained by separating resins from marijuana by solvent extraction, using solvents other than vegetable glycerin, such as butane, hexane, isopropyl alcohol, ethanol, and carbon dioxide.

so you can't make solvent extractions for home use but you *can* make vegetable glycerine extractions. Weirder. If the idea is to keep people from doing dangerous stuff with explosive solvents, this would be solved short of prohibiting "keep, or store homemade marijuana extracts", no?

In case you are wondering, vegetable glycerine extracts can be used in vape pen / e-cig type devices.

Alaska:

(b) Nothing in this chapter is intended to allow driving under the influence of marijuana or to supersede laws related to driving under the influence of marijuana.

I am sure Dr. McKnight realizes that when he asserts that "Biomedical research in the 1960s and 1970s was a spartan game" and "Biomedical research is a huge enterprise now; it attracts riff-raff who never would have survived as scientists in the 1960s and 1970s" he is in fact lauding the very scientists "When I joined the molecular cytology study section in the 1980s.. all kinds of superb scientists" who were the riff-raff the prior generation complained about.

From a very prestigious general Science journal in 1962:

Some of [this change] arises from expressions of concern within the scientific community itself over whether the NIH's rapid growth has sacrificed quality to achieve quantity.

And some of it reflects nothing more than the know-nothing ramblings of scientific illiterates, who conclude that if the title of a research project is not readily comprehensible to them, some effort to swindle the government must be involved.

Using data on all eligible subjects from all six studies, Allison et al. estimated that 280,184 obesity-attributable deaths occurred in the U.S. annually. When risk ratios calculated for nonsmokers and never-smokers were applied to the entire population (assuming these ratios to produce the best estimate for all subjects, regardless of smoking status, i.e., that obesity would exert the same deleterious effects across all smoking categories), the mean estimate for deaths due to obesity was 324,940.

Additional analyses were performed controlling for prevalent chronic disease at baseline using data from the CPS1 and NHS. After controlling for preexisting disease, the mean annual number of obesity-attributable deaths was estimated to be 374,239 (330,324 based on CPS1 data and 418,154 based on NHS data).

Over 350,000 Americans die annually of obesity. For the Republican Congresspersons in the audience, "annually" means every year. Last year, this year, next year. Over 350,000.

Researchers found that obesity accounted for nearly 20 percent of deaths among white and black Americans between the ages of 40 and 85. Previously, many scientists estimated that about 5 percent of deaths could be attributed to obesity.

So. Just this easily we can confirm that obesity is a major public health concern from mortality alone. This doesn't even get into non-mortal effect of obesity on personal well-being. Major public health concerns are the very province of NIH-funded academic research.

So once again, the applicability of grants that are targeted at reducing obesity (even if it is just understanding the causes of obesity) to the goals of the NIH, as mandated by Congress, is not in question. At all. This is not a frivolous expenditure.

That leaves us with the specific projects in question. I trotted over to RePORTER and pulled up 6 current awards- two are K-mechanism mentored training awards so we'll focus on the R-mechanism research projects.

nearly three-quarters of adult lesbians overweight or obese, compared to half of heterosexual women. In stark contrast, among men, heterosexual males have nearly double the risk of obesity compared to gay males. Despite clear evidence from descriptive epidemiologic research that sexual orientation and gender markedly pattern obesity disparities, there is almost no prospective, analytic epidemiologic research into the causes of these disparities. It will be impossible to develop evidence-based preventive interventions unless we first answer basic questions about causal pathways, as we plan to do.

I bolded a key part, from my perspective. You waste a ton of money, often public money, if you go off with solutions to problems without having a clear understanding of the things causing or following from this problem. Epidemiological and sociological research guides not just public policy but also additional studies of physiology, genetic liabilities, etc. So this specific project would seem to be of considerable use.

lesbian and bisexual (LB) women may be at elevated risk for developing T2D because they are more likely than heterosexual women to experience obesity and other risk factors linked with T2D such as cigarette smoking, violence victimization, and depressive distress. Nonetheless, knowledge of T2D and how it may disproportionately affect LB women is severely limited. Studies using longitudinal designs that have comprehensively examined how lifestyle, diet, and psychosocial risk factors for T2D may differ between LB and heterosexual women across the life course are virtually nonexistent.

This project emphasizes non-mortal morbidity, i.e., Type 2 Diabetes (T2D). And again, the abstract describes how we know almost nothing about the reasons for the obesity disparity between lesbian and heterosexual women. If we are going to disentangle potential social, behavioral, cultural, physiological and genetic contributors to the disparity, we need information. And very likely, through this research we will come to know more about how these variables affect obesity risk for all Americans, across all subpopulations. This will help us design better interventions to reduce the obesity burden. Clearly this is another grant that is clearly non-frivolous and fits into the public health mandate of the NIH.

Previous research indicates that lesbian, gay, bisexual and transgender (LGBT) adults experience more adverse health outcomes than their peers. Findings from the few studies examining weight disparities among adults suggest that lesbian women are more likely to be overweight or obese compared to their heterosexual peers, though less is known about gay men and bisexuals. Given the scant research to date in this area, the Institute of Medicine (IOM) recently issued a call for additional research on LGBT health. Furthermore, IOM highlighted the need to utilize a life-course framework when examining health disparities by sexual identity, acknowledging the unique influence of various life stages on health

What's this now? Even the US Institute of Medicine has reported on how important it is to combat obesity in US citizens? I mean dang, guys, it's the IOM.

The Institute of Medicine (IOM) is an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public.

Established in 1970, the IOM is the health arm of the National Academy of Sciences, which was chartered under President Abraham Lincoln in 1863. Nearly 150 years later, the National Academy of Sciences has expanded into what is collectively known as the National Academies, which comprises the National Academy of Sciences, the National Academy of Engineering, the National Research Council, and the IOM.

And they do investigations, review evidence, compare the facts...

anyway, this R21 is going to focus on young adults and do studies under the following Aims:

(1) Quantify disparities in obesity, dietary intake, physical activity, unhealthy weight control behavior, body satisfaction and other weight-related health outcomes among LGB and heterosexual students; (2) Identify major weight-related health behavioral patterns, or profiles, and the extent to which these behavioral profiles differ by sexual identity and gender; and (3) Characterize these behavioral profiles by demographic factors and health outcomes (e.g., age, socioeconomic status, health care coverage, obesity, and health status). We hypothesize that LGB students engage in more adverse behaviors than their heterosexual peers and exhibit differential behavioral patterning.

Yep, more psycho-social research but I continue to assert that without this evidence, we run the risk of wasting more money pursuing directions that could have been falsified by the epidemiological and social science studies of this type.

The final research project is an R15/AREA grant:R15 AA020424: MINORITY STRESS, ALCOHOL USE, AND INTIMATE PARTNER VIOLENCE AMONG LESBIANS

Ok, going by the Abstract this one is indeed focused on Alcohol abuse and intimate partner violence and I don't see why it is being triggered by the obesity keyword on the search. But still, I think we can see that this one ALSO would draw right wing fire. Even though, once again, alcoholism and intimate partner violence are huge health issues in the US.

As with the Origami Condom NIH Grant, we can find with relatively little thinking that the "National Institutes of Health (NIH) has spent more than $39 million on obese lesbians" comment is wrongly placed in an article addressing "wasteful" spending on the part of the NIH. These projects address the causes of obesity, which is basically a top predator of Americans at the moment. Obesity causes excess mortality and morbidity, which is of course associated with financial costs. Costs to the individual and costs to us all as a society that shares some degree of social support for the health care of our fellow citizens. It is in our direct and obvious interests to conduct research that will help us reduce this burden of obesity. As far as studying subpopulations who appear to be at increased risk for obesity goes, there is no reason not to want to help African-Americans, Southern Americans, Flyoverlandia Americans or...Lesbian-Americans. Right? And while it may take a little bit of a leap of faith for those who haven't thought hard about it, understanding the causes of a major health condition in those other people over there helps to understand the causes in people who are just like ourselves. By subtraction if by no other means.

For my regular Readers I'll close with a plea. Use analysis like this one to beat back this stupid meme that is going around about "frivolous" NIH expenditures. This is not just about this current Ebola fervor. This is about the normal operations of the NIH as it has progressed over decades. There are always those wanting to score cheap political points by bashing science as trivial or obviously ridiculous. Nine times out of ten, these charges are easily rebutted. So take the time to do so, even if it just posting some text pulled from the grant abstract and a link to a morbidity report on whichever health concern happens to be under discussion.

__
*"poorly considered" meaning he didn't apparently anticipate handing such a bunch of base-bait to the Republicans.

One of the NIH funded research projects that has been bandied about with much glee from the right wing, in the wake of Francis Collins' unfortunate assertion about Ebola research and the flatlined NIH budget, is the "Origami Condom". It shows why NIH Director Collins should have known better. The Origami Condom sounds trivial and ridiculous, right? "Origami". hahah. Oooh, "condom". Wait, what are we, 12 year olds?

But what really bothers me the most about this is that, rather than trying to exploit the current hysteria about Ebola by offering a quid-pro-quo “Give me more money and I’ll deliver and Ebola vaccine”, Collins should be out there pointing out that the reason we’re even in a position to develop an Ebola vaccine is because of our long-standing investment in basic research, and that the real threat we face is not Ebola, but the fact that, by having slashed the NIH budget and made it increasingly difficult to have a stable career in science, we’re making it less and less likely that we’ll be equipped to handle all of the future challenges to public health that we’re going to be face in the future.

In the event that you missed it, NPR has been running stories on the current situation with NIH-funded biomedical research in the US. These seem to be mostly the work of Richard Harris, so many thanks to him for telling these stories to the public. You will note that these are not issues new to this readership for the most part. The themes are familiar and, perhaps necessarily, latch onto one position and therefore lack breadth and dimension. Those familiar with my views on "the real problem" with respect to NIH funding will see many things I object to in terms of truthy sounding assertions that don't hold water on examination. Still, I am positively delighted that this extensive series is being brought to the NPR audience.

"When I was a very young scientist, I told myself I would only work on the hardest questions because those were the ones that were worth working on," he says. "And it has been to my advantage and my detriment."

Over the years, he has written a blizzard of grant proposals, but he couldn't convince his peers that his edgy ideas were worth taking a risk on. So, as the last of his funding dried up, he quit his academic job.

"I shouldn't be a grocer right now," he says with a note of anger in his voice. "I should be training students. I should be doing deeper research. And I can't. I don't have an outlet for it."

"If I don't get another NIH grant, say, within the next year, then I will have to let some people go in my lab. And that's a fact," Waterland says. "And there could be a point at which I'm not able to keep a lab."

He notes that the hallway in his laboratory's building is starting to feel like a ghost town as funding for his colleagues dries up. He misses the energy of that lost camaraderie.

"The only people who can survive in this environment are people who are absolutely passionate about what they're doing and have the self-confidence and competitiveness to just go back again and again and just persistently apply for funding," Waterland says.He has applied for eight grants and has been rejected time and again. He's still hoping that his grant for the obesity research will get renewed — next year.

PAULA STEPHAN: In many ways, the research university that's evolved today is much like a shopping mall.

HARRIS: She says think of universities as mall owners and individual scientists as the shopkeepers. Scientists get research grants and then pay rent to the universities out of that money. When grant funding doubled between 1998 and 2003, construction cranes went up all over the country to build more lab space.

STEPHAN: Universities were exuberant. They thought that they could keep running this kind of scheme - where the NIH budget would keep going up, and they could keep hiring more people.

HARRIS: But that didn't happen. After the NIH budget doubled, it stagnated. In fact it's declined more than 20 percent when you take inflation into account.